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00005768-200412000-0001500005768_2004_36_2093_reis_nonoccupational_12miscellaneous-article< 91_0_13_4 >Medicine & Science in Sports & Exercise©2004The American College of Sports MedicineVolume 36(12)December 2004pp 2093-2098Nonoccupational Physical Activity by Degree of Urbanization and U.S. Geographic Region[Basic Sciences: Epidemiology]REIS, JARED P.1,2; BOWLES, HEATHER R.3,4; AINSWORTH, BARBARA E.2; DUBOSE, KATRINA D.5; SMITH, SHARON6; LADITKA, JAMES N.31Division of Epidemiology & Biostatistics, Graduate School of Public Health, and 2Department of Exercise and Nutritional Sciences, College of Professional Studies and Fine Arts, San Diego State University, San Diego, CA; 3Department of Epidemiology and Biostatistics and 4Prevention Research Center, Arnold School of Public Health, University of South Carolina, Columbia, SC; 5Schiefelbusch Institute for Life Span Studies, Center for Physical Activity & Weight Management, University of Kansas, Lawrence, KS; and 6Urban Health Institute, Center for Health Disparities Solutions, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MDAddress for correspondence: Heather Bowles, M.S., Prevention Research Center, University of South Carolina, 730 Devine St., Columbia, SC 29208; E-mail: hrbowles@sc.edu.Submitted for publication October 2003.Accepted for publication July 2004.ABSTRACTPurpose: To estimate levels of nonoccupational leisure-time physical activity (LTPA) by degree of urbanization and geographic region of the United States.Methods: Participants were respondents to the Behavioral Risk Factor Surveillance System (BRFSS) in 2001 (N = 137,359). Moderate- and vigorous-intensity LTPA was categorized as meeting recommended levels, insufficient, or inactive. The U.S. Department of Agriculture rural-urban continuum codes were used to describe degrees of urbanization (metro, large urban, small urban, and rural). Geographic regions were defined by the U.S. Bureau of the Census (Northeast, Midwest, South, and West). Prevalence estimates were calculated using sample weights to account for the design of the BRFSS. Multivariate logistic regression analyses examined regional differences in the odds of physical inactivity (physically inactive vs insufficient or meets) by degree of urbanization after adjustment for sex, age, race, BMI, education, and occupational physical activity.Results: Large urban areas (49.0%) and the western United States (49.0%) had the highest prevalence of recommended levels of LTPA. Rural areas (24.1%) and the southern United States (17.4%) had the highest prevalence of inactivity. Adults living in the four urbanization categories of the midwestern (metro (OR = 1.47, 95% CI = 1.31, 1.65), large urban (OR = 1.83, 95% CI = 1.51, 2.23), small urban (OR = 1.99, 95% CI = 1.65, 2.40), and rural (OR = 2.59, 95% CI = 1.35, 4.97)); and southern (metro (OR = 1.70, 95% CI = 1.53, 1.88), large urban (OR = 2.04, 95% CI = 1.72, 2.41), small urban (OR = 2.32, 95% CI = 2.02, 2.67), and rural (OR = 5.49, 95% CI = 2.82, 10.68)) U.S. regions were more likely to be inactive than adults living in similar areas of the western United States. Adults in northeast metro and large urban areas (OR = 1.62, 95% CI = 1.45, 1.81; and OR = 1.37, 95% CI = 1.08, 1.74, respectively) were more likely to be inactive than those residing in western metro and large urban areas.Conclusion: The prevalence of physical inactivity varies by degree of urbanization and geographic region of the United States.Participating in regular physical activity has documented health benefits, including a reduction in cardiovascular disease (CVD) morbidity/mortality, lower rates of noninsulin-dependent diabetes mellitus, and protection against some forms of cancer (30). Despite the protective effects of physical activity against chronic disease incidence and progression, nearly half of all Americans do not participate in sufficient levels of physical activity to receive health benefits, and approximately one-third report performing no physical activity at all (12). This public health concern has led the U.S. Department of Health and Human Services to list physical activity as 1 of the 10 Leading Health Indicators (29).Regional variations in CVD mortality rates and the incidence of stroke and diabetes have been reported (14,16,17,19,20). Recent evidence suggests that geographic region of the United States (30) and degree of urbanization (13) are important correlates of adults’ participation in regular physical activity. Factors related to these findings might include seasonal weather influences and access to environmental supports for physical activity. Furthermore, two cross-sectional studies showed that rural adults report less environmental supports in their neighborhood that promote physical activity (21,32). Rural adults often have more poverty, lower levels of education, and less access to medical care and health facilities than those living in more urban areas (7). The purpose of this study was to provide national estimates of nonoccupational leisure-time physical activity (LTPA) participation by degree of urbanization and geographic region of the United States, using data from the 2001 Behavioral Risk Factor Surveillance System (BRFSS).METHODSParticipants and overview of the BRFSS.Participants were respondents to the BRFSS conducted in all 50 U.S. states and the District of Columbia in 2001. The BRFSS is an interviewer-administered telephone survey used to collect information relative to preventive health practices and risk behaviors among U.S. adults aged 18 yr and older. Survey methods for the BRFSS, discussed in detail elsewhere (5), employ a standard random-digit dialing method and weighted statistical sampling techniques designed to collect data representative of the U.S. population. In addition to preventive health practices and risk behaviors, the survey elicits information from respondents regarding demographic characteristics such as age, sex, weight, height, race, and educational attainment. To determine body mass index (BMI), weight in kilograms was divided by the square of height in meters. Informed consent was obtained from respondents by their willingness to complete the telephone survey after the interviewer explained the purpose and format. A total of 205,140 respondents residing in the United States completed the 2001 BRFSS survey. Respondents were excluded from analysis if they were missing information pertaining to demographic variables, LTPA, degree of urbanization, or geographic region of the United States. After exclusion for missing data, the final sample consisted of 137,359 adults.Physical activity assessment.Respondents were queried as to whether they engaged in moderate- and vigorous-intensity nonoccupational LTPA during a usual week. Moderate activities were assessed by asking whether respondents participated (for at least 10 min at a time) in brisk walking, bicycling, vacuuming, gardening, or any other activities that cause small increases in breathing or heart rate. To measure vigorous activities, respondents were queried as to whether they participated (for at least 10 min at a time) in running, aerobics, heavy yard work, or any other activities that cause large increases in breathing or heart rate. If respondents replied positively to either of these initial questions, they were subsequently asked to report the frequency (d·wk−1) and duration (total time per day) of those activities. The 2001 BRFSS was the first year these questionnaire items were used to quantify the usual participation in moderate- and vigorous-intensity activities. The physical activity module used in previous administrations of the BRFSS asked respondents to recall the frequency and duration of the two most popular physical activities performed during the past month.Responses to the physical activity items were used to classify respondents to one of three groups: 1) meets current LTPA recommendations (moderate-intensity physical activity ≥5 d·wk−1, ≥30 min·d−1, and/or vigorous-intensity physical activity ≥3 d·wk−1, ≥20 min·d−1 (22)); 2) insufficiently active (some moderate- and/or vigorous-intensity physical activity, but not meeting the recommendation); or 3) physically inactive (no reported physical activity). To identify associations among degree of urbanization and types of occupational physical activity, respondents employed for wages were asked to describe the demands of their occupation as: 1) mostly walking, 2) mostly sitting or standing, or 3) mostly heavy labor or physically demanding work.Degree of urbanization and region classification.Degree of urbanization was categorized based on the U.S. Department of Agriculture (USDA) rural–urban continuum codes, which describe counties by degree of urbanization and proximity to metropolitan areas (8). This classification scheme was developed to allow researchers to analyze county data by finer residential groupings beyond strictly metropolitan and nonmetropolitan areas. For the purposes of this study, we collapsed the 10 categories listed by the USDA into four categories: 1) metro, 2) large urban, 3) small urban, and 4) rural. Metro areas included counties located either on the fringe or central to metropolitan areas with a population ranging from fewer than 250,000 people to greater than 1 million. Large urban counties have a population of 20,000 or more, and may be adjacent to a metropolitan area, but are not located on the fringe or central to a metropolitan area. Small urban counties have a population of 2,500–19,999 and, similar to large urban counties, may be adjacent to a metropolitan area, but not located on the fringe or central to a metropolitan area. Rural counties have a population of less than 2500, and may be adjacent to a metropolitan area, but are not located on the fringe or central to a metropolitan area. To determine the association between physical activity and geographic region, states were grouped into Northeast, Midwest, South, and West regions, as defined by the U.S. Bureau of the Census.Data analyses.To adjust for the individual sampling weights and the design effects of the BRFSS, the SUDAAN statistical software package version 8.0 (Research Triangle Institute, Research Triangle Park, Cary, NC) was used to perform all analyses (27). Frequencies and prevalence estimates were calculated using sample weights to account for the design effects of the BRFSS. To maintain consistency with a previous report of geographic differences in physical inactivity from the 1996 BRFSS (11), physical inactivity was modeled as a function of geographic regions by degree of urbanization, using multivariate logistic regression analyses with adjustment for sex, age, race, BMI, educational attainment, and occupational physical activity. Meets recommendations and insufficiently active categories were combined, and served as the reference level. Statistical significance was determined through inspection of the 95% confidence intervals for the odds ratios.RESULTSTable 1 displays the demographic characteristics of respondents by degree of urbanization. There was little variation observed in the proportions of respondents by sex and age across the four degrees of urbanization. Overall, respondents were mostly non-Hispanic white, with the largest proportion living in rural areas. The proportion of respondents classified by BMI did not vary by urbanization. The largest proportions of respondents with a college degree and an occupation that required mostly sitting or standing lived in metro areas.TABLE 1. Demographic characteristics of respondents (N = 137,359) by degree of urbanization: 2001 Behavioral Risk Factor Surveillance System (BRFSS).Prevalence estimates of LTPA by degree of urbanization and geographic region of the United States are shown in Table 2. The lowest percentage of respondents classified as meeting recommended levels of physical activity lived in rural areas. The highest percentage of inactive respondents lived in rural areas. The prevalence of insufficient physical activity was similar across the four degrees of urbanization, though metro areas had a slightly higher prevalence of insufficiently active adults than the other three areas. The prevalence of recommended physical activity was highest in the West, and lowest in the South. Respondents classified as insufficiently active were similar across the four geographic regions of the United States. The prevalence of physical inactivity was highest in the South, and lowest in the West.TABLE 2. Prevalence of nonoccupational leisure-time physical activity (LTPA) by degree of urbanization and geographic region of the US: 2001 BRFSS.Figure 1 displays the prevalence of nonoccupational physical inactivity by degree of urbanization and geographic region of the U.S. Respondents in the West reported the lowest (metro 11.3%, large urban 10.5%, small urban 10.6%, and rural 9.6%), whereas those in the South reported the highest prevalence of physical inactivity across all four categories of urbanization (metro 17.0%, large urban 18.6%, small urban 24.5%, and rural 37.3%). Prevalence estimates of physical inactivity in the Northeast (metro 15.9%, large urban 11.1%, small urban 11.9%, and rural 12.2%) were similar to estimates of in the West, except within metro areas where the prevalence of physical inactivity was nearly 5% higher in the Northeast. Estimates of physical inactivity in the Midwest were 13.9% in metro areas, 15.6% in large urban areas, 19.7% in small urban areas, and 21.3% in rural areas.FIGURE 1— Nonoccupational leisure-time physical inactivity by degree of urbanization# and geographic region# of the United States: 2001 BRFSS; # see Appendix.Table 3 displays the results of multivariate logistic regression analyses investigating regional variations in the prevalence of physical inactivity by degree of urbanization after adjusting for sex, age, race, BMI, educational attainment, and occupational physical activity. Compared with respondents living in metro and large urban areas of the West, those living in similar areas of the Northeast were significantly more likely to be physically inactive during leisure time. Similarly, respondents residing in all four degrees of urbanization of the Midwest were more likely to be physically inactive compared to their western counterparts. Compared with the West, respondents living in the South had the greatest likelihood of being physically inactive among all four degrees of urbanization.TABLE 3. Logistic regression analyses of the prevalence of physical inactivity by degree of urbanization and geographic region of the US: 2001 BRFSS.DISCUSSIONThis paper describes the prevalence of physical activity by degree of urbanization and geographic region of the United States using data from a nationally representative sample of adults from all 50 states and the District of Columbia participating in the BRFSS in 2001. The prevalence of physical inactivity was highest in rural areas (24.1%), and lowest in metropolitan (14.6%) and large urban (14.1%) areas of the United States. Physical inactivity was also highest in the South (17.4%), and lowest in the West (11.2%). Interactive effects of urbanization and geographic region on the prevalence of physical inactivity were observed. When compared with the West, the likelihood of physical inactivity was highest in the South, with the odds of physical inactivity increasing from 1.70 in metro areas to a 5.49 increase in odds in rural areas.The current findings of increased rates of physical inactivity among rural adults are supported by other smaller cross-sectional studies investigating environmental correlates of physical activity behavior among men and women (4,21,32). These results are also consistent with an analysis of the 1996 BRFSS, which showed that adults living in rural areas reported the highest rates of physical inactivity, and that adults living in the western United States reported the lowest rates among nearly all degrees of urbanization (13). Furthermore, the 1996 BRFSS analysis showed that physical inactivity was highest among adults in the southern United States, ranging from 32% in metro areas to nearly 44% in the rural South (13). In the current study, physical inactivity ranged from 17.0% in metro areas to 37.3% in rural areas of the southern United States. Changes to the BRFSS physical activity questions in the 2001 survey to incorporate a broader range of physical activities might partially explain the decreased proportions of inactive adults between the 1996 and 2001 survey administrations. However, the results of this study display similar trends of increased physical inactivity among rural and southern United States adults, compared with other areas of the United States.An emerging area of the physical activity and public health literature has been focused on applying an ecological model to better understand how the physical environment and public policy affect physical activity behavior (24,25). This growing body of literature suggests that environmental characteristics such as access to facilities (e.g., walking trails, parks, swimming pools, and gyms), neighborhood sidewalks, streetlights, and enjoyable scenery are all positively associated with physical activity participation (1,4,6,21,26,31,32). However, there is evidence of self-reported differences in these environmental supports for physical activity between adults living in rural and urban areas. In a cross-sectional study comparing correlates of leisure-time physical activity among older urban (N = 1096) and rural (N = 1242) women participating in the U.S. Women’s Determinants Study, Wilcox et al. (32) showed that rural women were less likely (P < 0.001) to report streetlights and sidewalks in their neighborhood than women living in urban areas. Among 917 African American women living in rural communities in the southeast United States, Ainsworth et al. (2), noted that the presence of sidewalks and lighter traffic in one’s neighborhood was associated with performing regular moderate and vigorous physical activity. Parks et al. (21) studied a sample of 1818 men and women living in the United States and showed that urban, lower-income residents were more likely (P < 0.005) to report using neighborhood streets, parks, and malls to exercise than rural, lower-income residents. Although more empirical research regarding environmental correlates of physical activity is needed, the influence of these factors may help to explain the higher prevalence of physical inactivity among rural residents observed in the current study.The higher prevalence of physical inactivity in the southern United States is consistent with patterns of stroke incidence and mortality (18,23) and the prevalence of CVD risk factors (15,20) in the United States. A complex interaction of intrapersonal, interpersonal, environmental, and policy factors may contribute to the CVD morbidity and mortality rates observed in the South. Inadequate utilization of medical care and health services has been offered as an explanation for the increased stroke incidence among southern U.S. residents (3,9). Another report suggests that southern U.S. residents receive insufficient preventive counseling for physical activity participation and diet (11). Cross-sectional studies have also shown a relationship between low socioeconomic status and increased stroke mortality (10,28). Educational attainment and socioeconomic status are important correlates of physical activity participation (30), and have been shown to be lower in the South compared with other regions of the U.S (15,16).The BRFSS has several limitations that might influence the current findings. The cross-sectional nature of the BRFSS impedes the capacity to infer causality, due to the inability to determine a temporal relationship. Possible differences may exist between those who agreed to participate in the BRFSS and those who did not, as well as those without a residential telephone. A slightly higher percentage (approximately 5%) of women were deleted because of missing data; however, our findings were not affected by our exclusion criteria, due to similar estimates of physical activity between those with missing data and the sample reported herein. The reliance on self-report for the acquisition of physical activity data may have led to a misclassification of usual LTPA; however, self-report methodology is currently the most effective method of assessing physical activity for surveillance and epidemiologic purposes. An unequal number of respondents within each strata of urbanization resulted in a greater amount of variability, reducing the precision of the results.Despite these limitations, this study provides nationally representative data regarding participation in LTPA by degree of urbanization and geographic region of the United States. Furthermore, the BRFSS is currently considered the best available surveillance tool for assessing preventive health practices and risk behaviors of U.S. adults. Results from the BRFSS are used by states (29) to gauge progress towards meeting national health objectives. The inclusion of large numbers of respondents from all 50 U.S. states and the District of Columbia, and the weighted statistical sampling techniques, serve to ensure that the BRFSS sample is representative of the current U.S. population.In conclusion, this study compared the prevalence of physical activity in varying geographic areas of the United States by their level of urbanization. The prevalence of physical inactivity was highest in rural areas and the southern United States and lowest in metropolitan and large urban areas and the western United States. The likelihood of being physically inactive was highest among southern United States adults living in rural areas. Future studies that enroll participants from varying degrees of urbanization and/or geographic regions of the United States should consider these factors as potential correlates of physical activity participation.The authors are indebted to Dr. Caroline Macera for her helpful comments on an earlier draft of this manuscript.This study was completed while J. P. Reis, B. E. Ainsworth, K. D. DuBose, and S. Smith were with the University of South Carolina.There was no financial support for this study.APPENDIXDegree of urbanization.Metro = Counties located on fringe or central large metropolitan area with population ranging from fewer than 250,000 to greater than 1 million; Large Urban = Counties with population of 20,000 or more and may be adjacent to, but not located on fringe or central metropolitan area; Small Urban = Counties with population of 2,500–19,999 and may be adjacent to, but not located on fringe or central metropolitan area; Rural = Counties with population less than 2500 and may be adjacent to, but not located on fringe or central metropolitan area.Geographic region.Northeast = Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont; Midwest = Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin; South = Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, and West Virginia; West = Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. 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